Should Christians take antidepressants? Or is there spiritual benefit in suffering through depressed moods? Are antidepressants overprescribed? Are they more harmful than helpful? How should Christians think about antidepressant therapy? How thoughtful Christians ought to think about treatment with antidepressant medications is, I shall suggest, tightly linked to how thoughtful Christians ought to think about human bodies and about pain.

As William James points out above, depression, especially in its most severe forms, is often experienced as psychical pain. What he does not there point out, however, is that depressive disorders are not wholly restricted to the realm of experience: significant depression is also accompanied by myriad systemic changes in one’s body. Many depressed persons lose their appetite, become constipated, feel fatigued, experience muscle aches, and have trouble sleeping. What’s more, persons afflicted with clinical depression have a doubling of mortality at any age (independent of smoking, other risk factors related to poor health, and suicide), a loss of brain cells, metabolic problems involving insulin, increased susceptibility to inflammation, and impaired bone development. Depression, therefore, is best viewed as an integrated, “psychosomatic” disorder—a disorder of mind and body—a disorder of the whole person.

Darkness Visible. The painful aspects of depression are perhaps nowhere better described than by Sophie’s Choice author, William Styron, in his autobiographical Darkness Visible.2 On the one hand, Styron speaks of “my dank joylessness” (p. 5) and of being “shaken by the certainty…[that] I would never recapture a lucidity that was slipping from me with terrifying speed” (4) as if “my mind was dissolving” (13). On the other hand, however, and above all, Styron speaks vividly about the pain of depression. “I was,” he said, “feeling in my mind a sensation close to, but indescribably different from, actual pain.… Healthy people” have a “basic inability…to imagine [this] form of torment so alien to everyday experience. For myself, the pain is most closely connected to drowning or suffocation—but even these are off the mark” (17). He adds,

In depression, faith in deliverance, in ultimate restoration, is absent. The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come—not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow….So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying—or from discomfort to relative comfort, or from boredom to activity—but moving from pain to pain. One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes. (62)

Styron is not here describing simple sadness or “the blues.” He is not describing an experience “common to man.” Rather, Styron is describing deep emotional torment, a torture of the soul, something akin to the pains of loss and the pains of sense ordinarily associated only with hell.

The Pain and Treatment of Depression. We can thank God, however, that not all depression is like this. Not all depression is dominated by mental pain. Some depression is dominated by sadness more than by pain, or by a lack of pleasure (anhedonia), or by boredom, or by a feeling of aloneness. The pain of depression is a critical starting point when examining the ways that a Christian ought to think about the treatment of depression. Many Christians already have a fairly good idea how other pains—pains whose sources feel as if they are grounded in the body rather than in the brain—are best treated, namely, some are treated with medications, some with manipulation, some by reinterpreting the meaning of one’s pain, some with electricity, some with surgery.

And so it is with depression: some depression is best treated with antidepressant medications, some with exercise, some by talking, some with electroconvulsive therapy, and some especially severe cases with surgically implanted deep brain stimulation. And, of course, just as with bodily pains, all mental pain is optimally treated also with prayer, sometimes with fasting, a renewed turning back to God, forgiveness, discernment of spirits, gratitude for God’s manifold gifts, love, and acceptance, with as much joy as one is able to contain in whatever one’s circumstances.

There is also another important reason to focus on the pain of depression; namely, as bodily pain has a bodily basis, so too mental pain has a bodily basis—our brains. This is not to say, first, that depression is simply a brain disorder. It is that, but more. And it is not to say, second, that only physical means will ameliorate depression—some physical means will and some will not. And, third, it does not mean that mental and spiritual factors have not played pivotal roles in the genesis of the depression, for such factors clearly have profoundly important roles to play in most depressive disorders.

What is Depression? To say, first, that depression is a brain disorder—although not merely a brain disorder—is to say that clinically significant depression is always accompanied by a disordered brain. In fact, for any given mental state that is abnormal, there is a correlative brain state that is abnormal. This is not to say that all mental states are brain states, but only that mental states and brain states are so tightly linked that a disturbance in the former is sure to be associated with a disturbance in the latter.

Even the great seventeenth-century philosopher Rene Descartes, the father of modern mind-brain dualism, believed this, stating, in a very famous passage in the Sixth Meditation: “I am not only lodged in my body as a pilot in a vessel, but I am very closely united to it, and so to speak intermingled with it that I seem to compose with it one whole.” Descartes appears here to suggest that the brain is more than the mind’s instrument, but rather exists in some sort of deep unity with it.

Similarly, Aristotle and, especially, St. Thomas Aquinas (and through Aquinas, the bulk of the Christian tradition through history), views mind, or more accurately, soul, and body as deeply united. So much so, in fact, that the soul and the body constitute a single thing, a human person, who is identified not merely with the soul, but with the “soul-body composite.” After death, therefore, when I temporarily exist in a state of disembodiment, strictly speaking, the soul that exists is not fully me; rather, it is the glorified soul-body composite that is me, the human person that I am. The resurrection of the dead is, as was our Lord’s, a bodily resurrection: we are not complete, whole, fully us without our bodies. Our bodies are not merely dispensable parts of us, they are not extrinsic to who we really are; rather, they are intrinsic to us, parts without which we would not be. Therefore, to treat our disordered brains is to treat us, not to treat some extrinsic, peripheral, dispensable part of us. In the appropriate circumstances, therefore, to treat our brains physically when we are disturbed emotionally is one way to make us whole again.

Second, there is a fallacy in the claim—a claim that I often hear, especially in the context of discussions concerning sexual orientation—that the origin of a disorder requires a purely “matching” treatment, such that if a problem has a psychological cause, it requires only psychological treatments; if a problem is spiritually based, then only spiritual treatments will do; and if a problem has a physical cause, it can only be treated physically. Those who fall for this fallacy worry that if, for example, homosexuality is strongly biogenetically determined, then it would be implausible to think that psychological therapies could reverse it; or, if alcoholism is a medical (i.e., biological) disease, then it requires medical (i.e., biological) treatment. On the contrary, because we are unified beings, we ought to expect that psychological, spiritual, and physical treatments might play pivotal roles in reorganizing states of disorder in us regardless of whether these have psychological, spiritual, or physical causes.

This suggests that, third, psychological causes of brain and emotional disorder can be profitably treated with physical means (e.g., antidepressants). This is not to say that antidepressants are the best treatments for all depressions. (They are not. In fact most diagnosable depressive conditions are likely best treated with something other than antidepressants.) Nor is this to say that only medication therapy is the optimal choice even for those depressions for which antidepressants are appropriate. Although the psychiatric literature is inconsistent on this point, there is evidence that a combination of pharmacotherapy and psychotherapy is better than pharmacotherapy alone for the treatment of some depressions, but that pharmacotherapy tends to work faster than psychotherapies and that it tends to be more effective than psychotherapies for more severe depression (especially when depression is so severe as to be accompanied by hallucinations and delusions).

Addressing Both Physical and Emotional Pain. So, are antidepressants overprescribed? Yes. And are antidepressants also underprescribed? The answer to this question is also “Yes.” Might one who is taking antidepressants benefit more by working through his or her depression in other ways (psychologically, spiritually, socially), identifying with our Lord in one’s suffering, listening to the messages that depression communicates, relying more on God, repenting of sin, and striving to inculcate the virtues? The answer to that question is also “Yes.” On the other hand, might one who is depressed but who is not taking antidepressants benefit from the drugs’ ability to enhance mood in a manner that would optimize one’s ability to serve God, love others, and care for one’s family, one’s body, and one’s soul? The answer to that question, likewise, is “Yes.” Relieving suffering by relieving physical pain is, in multiple respects, very much like relieving suffering by relieving mental pain. And just as there are myriad ways to address physical pain, there are also myriad ways to address emotional pain. Which method of pain relief is best for which patient is a matter of discernment. Fortunately, Christians are in the business of discernment (1 John 4:1). May we discern well, love well, and thrive.

—A. A. Howsepian

A. A. Howsepian, M.D., Ph.D., is an assistant professor of philosophy in the University of California, San Francisco-Fresno Medical Education Program whose many articles can be found in philosophy, bioethics, psychiatry, and neurology journals. His Ph.D. is in philosophy from the University of Notre Dame.

NOTES

William James, (1902), The Varieties of Religious Experience (Reprinted, [1999], New York: The Modern Library), 65.